Keeping Your Reimbursement Should Not Be More Difficult Than Getting Paid!

As a reimbursement consultant to the wound management industry, I receivemany questions about coding, coverage, and payment. The questions typically fall into 3 categories: 1) How should I code for a service, product, or procedure? 2) Why didn’t I get paid? and 3) Why did I incur a repayment after an audit? If everyone knew the correct code, they would get paid and not incur any repayments, but somehow there is a disconnect between the encounter and claim submitted. To help you better understand why this occurs, take a few moments to answer 5 critical questions honestly:

1. Have you researched all the medical policies (from Medicare and other payers) pertaining to every service, product, and procedure you provide?

2. Do you know your Medicare Administrative Contractor’s (MAC) documentation requirements for every service, product, and procedure you provide?

3. Have you printed and compared your documentation with the MAC’s requirements?

4. Have you reported the code that accurately reports the service, product, or procedure, or did you report the code based on the payment rate that you wanted?

5. Have you appended modifiers to codes when they were justified by documentation, or to cause payment of the claim?

Congratulations if you answered, “Yes,” to all 5 questions. If you answered, “No,” to one or more of the questions, I highly recommend that you make a concerted effort to turn any “no” into a “yes.” Otherwise, you may face claim denials or, worse yet, repayments after one or more audits. I am always sad when wound management professionals receive denials or repayment and say, “No one told me how to document and code correctly.” When we bill Medicare, or any other payer, we must know their coding, coverage, and payment policies. In addition, if we have contracts with private payers, we must read our contracts and their medical policies. Let’s review some major repayments that would not have occurred if the provider had learned pertinent reimbursement guidelines.

Example 1. Dr. Smith reported and was paid for 19 applications of a cellular- and/or tissue-based product (CTP) for skin wounds (outdated term, “skin substitute”) on a diabetic foot ulcer. After an audit, Dr. Smith had to repay for 9 applications because the MAC covered only 10 applications, and Dr. Smith never documented the need for additional applications. Dr. Smith did not know that the MAC’s local coverage determination (LCD) limited the number of applications. In fact, Dr. Smith never read the LCD or its accompanying local coding article (LCA). The audit taught Dr. Smith that when an LCD and/or an LCA exists, it/they should be the “play book” for wound management.

Example 2. Dr. Jones has a busy podiatric practice and sees approximately 40 wound management patients per day. Because Dr. Jones reported many more surgical debridements and applications of CTPs than other podiatrists in his state who do not specialize in wound management, Dr. Jones was audited. If Dr. Jones’ documentation had met the MAC’s documentation requirements for debridement and application of a CTP, he would have passed the audit without any problem. Unfortunately, Dr. Jones’ documentation did not include the “why, what, where, how, and how much” requirements for these surgical procedures. Therefore, the auditor declared that the work was not medically necessary and recouped nearly all payment times 3. When I spoke with Dr. Jones, he remembered one of my classes and hearing me discuss the documentation requirements for surgical procedures such as debridement and application of CTPs. However, because he was always paid for the procedures, he did not think it was necessary to take the time to improve his documentation. This was a difficult and expensive way to learn the true meaning of, “If it is not documented adequately, it will not be considered medically necessary.”

Example 3. Dr. Lewis performs hyperbaric oxygen therapy (HBO) in her office and documents via an electronic health record (EHR). When her office was informed that Dr. Lewis was being audited for many HBO encounters, the office manager printed and submitted the requested medical records. When Dr. Lewis received the audit report, she was shocked to learn that she had to repay for nearly every encounter. Dr. Lewis contacted me to see if I could find a way for her to overturn the audit findings. I asked for a copy of all records submitted to the auditor and compared Dr. Lewis’ documentation with the MAC’s HBO LCD and LCA. The documentation did not even come close to addressing all the MAC’s requirements. In addition, the documentation contradicted itself for many encounters (eg, in many cases, the documentation said that the wound was healed, but HBO therapies were continued for many weeks). Because I could not believe that Dr. Lewis would perform HBO procedures that were not medically necessary, I asked her if she had ever printed and read the documentation that was generated by her EHR. Her answer was, “No.” Therefore, I requested that Dr. Lewis print the HBO National Coverage Determination and her MAC’s LCD and LCA and then compare the printed documentation against those coverage guidelines. Dr. Lewis was shocked that the documentation did not align with the coverage requirements, was disjointed, contradicted itself, and simply did not present a clear picture of the why, what, where, how, and how much HBO requirements. Dr. Jones had trusted that by completing each EHR screen she was meeting the HBO coverage guidelines. She learned the hard way that wound management professionals must read the printed version of their EHR documentation and take ownership to align EHR templates with the coverage requirements for each service, product, and procedure that they provide.

Example 4. Dr. Kelly works in a hospital-owned outpatient wound management provider-based department (PBD). He debrides every patient’s wound at nearly every encounter but does not document the level of tissue debrided. The wound care certified nurses who work for the PBD always document the wound assessment before and after debridement, level of tissue that was removed, primary and secondary dressing applied, use of compression bandages or offloading, and patient education provided. Dr. Kelly always codes his work as debridement of subcutaneous tissue, 11042. The PBD always codes the debridement they supported by the level of tissue that Dr. Kelly debrided. Most often, the PBD reports 11042 or 11043 for the first debridement performed. On following visits, the PBD typically reports selective debridement 97597 or 97598 because Dr. Kelly is usually debriding exudate, debris, or biofilm.

I was contacted by the PBD to provide a virtual debridement coding education program. During the program, Dr. Kelly challenged my direction to report the debridement code based on the level of tissue removed. He said that the selective debridement codes are only for therapists, that he always reports 11042 and gets paid every time, and that he will not use 97597 or 97598 because their allowable rate is lower than the allowable rate for 11042. About 6 months later, Dr. Kelly was audited and incurred a sizeable repayment for nearly all debridements performed because he did not thoroughly document the procedure and because he reported debridement of subcutaneous tissue even when he debrided muscle, exudate, debris, or biofilm. Dr. Kelly could have prevented this large repayment by carefully reading the code descriptions for the surgical debridement and selective debridement procedure codes, by thoroughly documenting his work, and by reporting the code that accurately represented the work performed. Dr. Kelly was then convinced that selective debridement codes are not just for therapists!

Example 5. Another PBD had a post-payment audit of many claims and was facing a large repayment. I was contacted to review the exact claims that were audited, and the PBD hoped that I would find that the auditor was incorrect. Unfortunately, I was not able to prove that the PBD coding was correct because they did not follow the National Correct Coding Initiative (NCCI) edit manual and procedure-to-procedure edits. Nearly every claim listed at least one code that should not have been reported (per the NCCI edits) because it was a component of another code. However, the hospital coders inappropriately applied modifiers that allowed the claims to be paid. When the auditors and I reviewed the PBD’s documentation, we usually found that the modifiers were not warranted because 1) a clinic visit was reported with modifier 25 for an encounter when a minor procedure was performed but a significant separately identifiable problem was not assessed and managed, or 2) a procedure that was a component of another procedure was performed on the same anatomic location but was reported (with modifiers such as 59, XS, or XU) as if it were not performed on the same anatomic location. Therefore, I taught the PBD and hospital coders how to locate the NCCI manual, how to read the chapters that pertained to their work, and how to search the NCCI procedure-to-procedure edit files for code pairs that they typically perform at the same encounter. They are no longer using modifiers inappropriately.

I hope that you will quickly implement any documentation or coding refinements necessary to allow correct payment and prevent repayments. Take the time to establish an efficient process, learn documentation requirements, document accurately at the time of the encounter, learn the codes (and their exact definitions) that represent the work that you perform, understand the NCCI edits that pertain to the code pairs that you perform, and only use modifiers when they are appropriate. As a wound management professional, you perform medical miracles and should be paid appropriately—not too little, not too much, but exactly right. Then you will easily pass audits and will not face repayments.

Ms Schaum is the Founder and President of Kathleen D. Schaum & Associates, Inc., which provides reimbursement education and consultation to wound/ulcer management professionals and manufacturers. Kathleen can be reached at kathleendschaum@bellsouth.net or at 561-670-7176.
The opinions and statements expressed herein are specific to the respective author and not necessarily those of Wound Management & Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.